Streptococcal Toxic Shock Syndrome

Streptococcal toxic shock syndrome (STSS) is a severe, rapidly progressive illness associated with either invasive or noninvasive group A streptococcal infection. This syndrome may occur with infection at any site but is most often associated with a cutaneous lesion. To be considered as STSS, all the following manifestations must be present within 48 h of hospitalization:

1. Hypotension: systolic blood pressure less than 90 mmHg for adults or less than the fifth percentile by age for children under 16 years of age.

2. Multiorgan involvement with two or more of the following:

a. Renal: Creatinine greater than 2 mg/dL for adults, or twice the upper limit of normal for age, or twice the baseline value for persons with underlying renal dysfunction.

b. Coagulopathy: Platelets less than 100,000/pL or disseminated intravascular coagulopathy.

c. Hepatic: Total bilirubin, alanine aminotransferase, or aspartate aminotransferase twice the upper limit of normal for age or twice normal baseline values for those persons with underlying liver disease.

d. Respiratory: Adult respiratory distress syndrome.

e. Dermatologic: Generalized erythematous macular rash that may desquamate.

f. Musculoskeletal: Soft tissue necrosis including necrotizing fasciitis, myositis, or gangrene.

The laboratory diagnosis is made by isolating group A Streptococcus in a normally sterile site. SYPHILIS

The manifestations of syphilitic illness vary with the time period between infection and detection. Primary syphilis is recognized by the one or more chancres, usually on the genitalia. Secondary syphilis is identified by the presence of localized or diffuse mucocutaneous lesions. The primary chancre may still be present. Laboratory diagnosis for primary or secondary syphilis rests on demonstrating Treponema pallidum by dark-field microscopy, direct fluorescent antibody (DFA-TP), or equivalent method.

Latent syphilis has no clinical symptoms. The early latent period occurs in those infected within the previous 12 months, and the late latent period refers to those infected for greater than 1 year. Persons in whom the period of infection cannot be documented and in whom there are no clinical symptoms are referred to as being latent of unknown duration. Laboratory diagnosis of latent syphilis can be made in one of the following ways: (1) no past diagnosis of syphilis and a reactive nontreponemal test (VDRL or RPR) and a reactive treponemal test (FTA-ABS or MHA-TP) or (2) history of syphilis therapy and current test titer with fourfold increase from last nontreponemal test titer.

Neurosyphilis is evident by the presence of CNS findings in the setting of a reactive serologic test for syphilis and a reactive VDRL in cerebrospinal fluid. Late syphilis with clinical manifestations other than neurosyphilis is manifested by inflammatory lesions of the cardiovascular system, bone, and skin. Rarely, lesions of the upper or lower respiratory tracts, mouth, eye, abdominal organs, reproductive organs, lymph nodes, or skeletal muscles occur. Evidence of late syphilis is seen after more than 15 years of untreated infection.

Syphilitic stillbirth is fetal death after at least a 20-week gestation or in a fetus weighing greater than 500 g in which the mother had untreated or inadequately treated syphilis at delivery. This should be reported as congenital syphilis.

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